Patient Satisfaction Questionnaire

We are pleased that you and your Doctor chose our center for your outpatient procedure. We hope that your stay with us was comfortable and pleasant. Our goal is to provide high quality medical care to our patients and their family members. That is why we invite your response to this questionnaire.

With your help, the staff can evaluate how effectively we are meeting the challenge of providing you with quality health care. Your comments and response will be thoroughly reviewed and kept strictly confidential unless you specify otherwise.

Thank you for taking the time to respond to this questionnaire.

Please give us your confidential opinion…
Highest  —   A     B     C     D     E     F  —  Lowest

1.	How would you rate the phone call (Pre-op assessment) you received the day before surgery?
	Information adequate	A   B   C   D   E   F
	Questions answered	A   B   C   D   E   F
	Pre-op nurse courteous	A   B   C   D   E   F
2.	How would you rate the Admitting Staff?
	Greeting upon arrival	A   B   C   D   E   F
	Efficient/Prompt	A   B   C   D   E   F
	Courteous/Concerned	A   B   C   D   E   F
	Attentive	A   B   C   D   E   F
	All questions answered	A   B   C   D   E   F
3.	How would you rate the facility?
	Clean	A   B   C   D   E   F
	Comfortable	A   B   C   D   E   F
	General atmosphere	A   B   C   D   E   F
	Convenience/Accessibility	A   B   C   D   E   F
4.	How would you rate the Anesthetic practitioner who provided your anesthesia care?
	Prompt	A   B   C   D   E   F
	Efficient	A   B   C   D   E   F
	Courteous	A   B   C   D   E   F
	Knowledgeable	A   B   C   D   E   F
	Adequate Explanation and Directions	A   B   C   D   E   F
5.	How would you rate the Nursing Staff in the Recovery Room?
	Prompt	A   B   C   D   E   F
	Efficient	A   B   C   D   E   F
	Courteous	A   B   C   D   E   F
	Concerned	A   B   C   D   E   F
	Post-operative Instructions explained	A   B   C   D   E   F
6.	How was your pain managed during your stay?
	Promptly	A   B   C   D   E   F
	Completely	A   B   C   D   E   F
7.	What was your general impression of Rush SurgiCenter?
		A   B   C   D   E   F
8.	Would you return to Rush SurgiCenter should you require further health care services?
	Yes   No
9.	Would you be willing to refer a family member or friend to Rush SurgiCenter for treatment?
	Yes   No
10.	Was this your first visit to Rush SurgiCenter?
	Yes   No
11.	Did the Web site meet your needs?
	Yes   No
	Please provide any additional comments:

OPTIONAL AND CONFIDENTIAL
	Name:
	Address:
	City, State Zip:
	Date of Surgery: